Docs are conflicted over drug reps’ gifts

Early in my first year of medical school, I was asked to sign a letter indicating that I promised to refuse gifts from pharmaceutical or medical-device manufacturing companies. I would give up lunches, pens and (if I were exceptionally lucky) free trips to faraway places.

I declined to sign. I thought myself intelligent enough to take a pen without unconsciously feeling wedded to whatever brand of anti-hypertensive decorated the exterior. In addition, I was at least three years from prescribing anything to anyone. Therefore, I reasoned, I could take all the pens and Indian food that came my way. When I really had some power, then I guess I could reconsider. And it wasn’t like I was accepting any trips to the Bahamas or anything. A pen is worth less than a dollar.

The problem is, study after study has demonstrated that even little gifts like pens and lunches make a big difference in the prescribing habits of doctors. And developing relationships with doctors while they are still in training in medical school and residency is exceptionally effective. Most doctors develop their prescribing habits during this time. The drugs they learn to use in training are the drugs they are most likely to continue using throughout their career. This should have been no surprise. Big pharma is a sophisticated marketing machine. If the gifts didn’t work, they would have stopped giving them out.

Some states have begun requiring that pharmaceutical and medical-device companies disclose their marketing strategies: What do they give, and to whom? Lists of doctors and the gifts they have received have started to show up in registries. This has rightfully made some people uncomfortable. The idea is that if you are forced to disclose that AstraZeneca paid for your jaunt to Scotland, then maybe you’ll be less likely to accept such egregious gifts.

But disclosure has its own set of problems. Studies of conflict-of-interest disclosures in the context of research trials (many principal investigators are paid honoraria as pharmaceutical consultants or speakers, and drug makers often sponsor the trials that their drugs are involved in) show that disclosure does not necessarily benefit the patient or study participant. Patients interpret the conflict of interest as “solved” if it is disclosed. Instead of inviting closer scrutiny of the relationship between the doctor and sponsor, it appears to discourage questions and make the study participants feel more comfortable, not more suspicious. This is understandably a big problem and has spawned discussion about whether conflict-of-interest disclosure is really in the interest of the patient or if it just makes the doctor feel better.

Some physicians would argue that allowing drug reps access to their clinics provides free drug samples that are then available to patients who wouldn’t otherwise be able to afford their medication. In return for the free drugs, the pharmaceutical salesperson is granted five or 10 minutes of the physician’s time to “educate” him or her about the newest data supporting the drug they’re currently pushing. Free drugs certainly help to keep some patients healthy. But in addition to the biased “education” the physician receives — making him or her more likely to prescribe a particular drug — the samples provided are often only the newest and most expensive drugs. Older generic drugs are not provided as samples because the pharmaceutical companies have no interest in promoting drugs from which they make only a slim profit margin. There is a significant disadvantage to starting an expensive drug regimen in a patient who receives samples because his or her lack of insurance make even the cheaper generics financially out of reach.

Yale officially banned pharm reps from the hospital and medical school shortly after I arrived on campus. But this ban is only partially enforced. Device reps still often enter operating rooms to “advise” the surgeon on how to use the pricey hardware they’re selling, often talking up the newest, most expensive product while they’re around. And some departments simply moved their pharma-catered lunches across the street after the ban.

I must admit, despite the evidence, I’m still conflicted about the pens and food. It seems like everyone around me has no qualms about these gifts. Resident physicians at the hospital often get excited about pharma-sponsored dinners at Bentara or Central Steakhouse. I can’t help but feel uneasy about the expensive meals, but I still often take the pens. Maybe tomorrow I’ll head off to Staples and buy a big bag of Bics.

Karl Laskowski is a 2003 graduate of Yale College. He is a fifth-year student in the Yale School of Medicine.